01.07.15
Urgent and emergency care review
Source: NHE Jul/Aug 15
Dr Caron Morton, co-chair of the Urgent and Emergency Care National Steering Group, gave a presentation at the Commissioning Show outlining what to expect from the review between now and 2017.
Urgent care has to change fundamentally and cannot remain focused on A&E, according to Dr Caron Morton, the accountable officer at Shropshire CCG who is leading the national review of urgent and emergency care.
Giving an update at the Commissioning Show 2015, she said the winter pressures showed that the system was on the edge already – it didn’t take much to push it over. “The surge problem isn’t about attendances, it’s about admissions – and the fact that community [services are] full,” Dr Morton added. She also busted some myths on what is causing the pressure on the system. “Everyone says it’s the old people in A&E causing pressure on the system – it isn’t, it’s all of us. The attendances and admissions have grown in every age group.
“Everyone says we keep patients in hospital too long. We aren’t; length of stay has reduced dramatically. It’s the balance that we’re not able to get.”
What actually is happening, she said, is congestive hospital failure, with the balance between demand and efficiency breaking down. “You’ve got outlying patients with issues with delayed transfers of care, issues with nursing with staff being [un]able to cope. You’ve got your escalation wards open and often they’re completely full as well. You’ve increased your bed numbers, there’s a backlog in A&E, you’re breaching your four-hour target, ambulances are queuing which means they can’t get to 999 calls, and your whole system externally starts to back up.
“The cogs are very important, because the urgent care system works through this cog system and when it starts to slow down it doesn’t take much for it to stop completely.”
So what is the review going to do to try to fix this problem? “What we decided to do with the national review was focus on where the vast majority of patients are being seen, rather than concentrate on A&E and the emergency side as usual,” Dr Morton said.
New model
A new model of an inverted triangle has been developed to represent where most patients are being seen and where commissioners and providers need to focus and put their resources. It uses colours to differentiate between the urgent and time-critical emergencies, with red as time-critical.
Dr Morton said: “We will see all patients but it is not necessarily time-critical – and we have to get that separation for those A&E departments to flow and to work and for patient care to be safe.”
Between now and 2017, a lot of changes are being delivered to urgent and emergency care. A top priority is strengthening clinical involvement in 111 and 999. By 2017, patients ringing these services will have access to full clinical triage and 111 will be able to book urgent GP appointments. It will also be able to fast-track patients to the relevant clinician over the phone. A 111 digital platform will also be integrated into the NHS Choices website.
The aim is to increase the proportion of calls to 111 and 999 that are resolved through ‘hear and treat’, rather than having to dispatch an ambulance or have the patient attend an urgent care centre.
Dr Morton said that for those who do need to visit an urgent care centre, however, by September 2017 they will have an allocated appointment slot and will not need to queue.
Another major development is a plan to roll-out a service directory to everyone in the urgent care pathway. Dr Morton says this will be integrated into tablets and mobile phones and will allow urgent care workers to direct the patient properly through the system.
A key part of this is a change to referrals. “Within the urgent care pathway, wherever you are, you can refer directly through to the specialist services that are needed – you don’t have to stop at the next level above you,” Dr Morton said.
Dr Morton said most mental health provision in a crisis should always happen in the patient’s home. Anyone in mental health crisis who presents at A&E will also receive an assessment by a liaison mental health service.
She also addressed the pending ‘urgent and emergency care networks’. These are to be based on geography, to give a strategic oversight to regional urgent and emergency care.
Each network will deal with between one and five million people, depending on the area they cover. They will coordinate, integrate and oversee care and set shared objectives for certain services to achieve commonality for the delivery of care. Some of the potential areas they will look at include ambulance protocols, NHS 111, clinical decision support and access protocols to specialist services.
Dr Morton said that guidance has gone out on creating the networks and that a route map is expected from NHS England on how the urgent and emergency care review will be implemented and the networks established and supported.
The presentation slides are here